Large quality gaps exist between scientifically proven therapies and the care that is actually delivered. My long term career goals are to 1) generate the knowledge to fill such quality deficits by identifying the relevant barriers and 2) design and implement quality improvement (Ql) interventions that address those barriers. Diabetes mellitus (DM) and chronic kidney disease (CKD) are both coronary heart disease risk equivalents and associated with increased mortality, primarily due to cardiovascular disease (CVD). Paradoxically, patients with DM and CKD are at greatest risk yet less likely to receive CVD-preventive medications: underutilization of such medications (aspirin, angiotensin antagonists, and statins) is widespread. The reasons why 20-40% of these high-risk patients do not receive these beneficial therapies are not known. Potential barriers at the physician, patient, and systems-levels include: physician knowledge and attitudes, kidney function measurement factors, medication related factors, competing demands and prioritization, and organizational factors. For this career development award, we will determine which physician, patient, and organizational barriers actually limit the delivery of adequate CVD-preventive medications. Through focus groups of patients and physicians within 2 health systems and 6 clinics, we will develop patient chart review and physician survey instruments. The charts of 1,250 patients with DM and CKD will be abstracted and their physicians will be surveyed. The patient, physician, and system-level predictors of suboptimal prescribing will be explored through bivariate and multilevel analyses by linking patients'outcomes (i.e. CVD medication prescriptions) to providers'survey responses. We will also determine the maximum achievable utilization rates of the-3 CVD medication groups at different levels of kidney function;information important for quality assessment and designing future studies to improve prescribing. Findings from these studies will provide the knowledge necessary to design a Ql intervention that is tailored to overcome the specific barriers identified. To gain proficiency in trial design and implementation, the career development components of this Award include completion of a Masters degree in Clinical Research and superb multidisciplinary mentorship. Combined with the proposed research studies, this training will allow me to become an independent clinical investigator who is well-poised to make significant contributions to the care of patients with CKD.